2型糖尿病患者糖皮质激素变化的临床研究

目的　探讨 2型糖尿病患者糖皮质激素分泌变化的规律及其临床意义。方法　测定 2 2名健康人 (对照组 )和 6 3例 2型糖尿病患者 (其中 39例 2型糖尿病无微血管病变、2 4例 2型糖尿病并微血管病变 )的血皮质醇 (F) ( 8Am、4Pm )、2 4h尿游离皮质醇 (UFC)及血糖 (FBG、2hPG)、HbA1c、TC和TG。结果　 2型糖尿病组的血F( 8Am、4Pm)及 2 4hUFC与对照组比较 ,差异有显著性 (P <0 .0 5 )。糖尿病有微血管病变组的 2 4hUFC的排量高于无微血管病变组 (P <0 .0 5 )。糖尿病组 2 4hUFC与HbA1c呈正相关 (r =0 .2 76 ,P <0 .0 5 ) ,与病程呈正相关 (r =0 .72 4,P <0 .0 1) ,与 2 4h尿微量白蛋白 (UAP)呈正相关 (r =0 .486 ,P <0 .0 1) ,与TG呈正相关 (r= 0 .42 1,P <0 .0 1)。结论　 2型糖尿病患者糖皮质激素水平增高 ,加重了糖代谢和脂代谢紊乱 ,使糖尿病患者的病情恶化 ,最终促使糖尿病并发症的发生。     

Depressive symptomatology as a risk factor for increased health service utilization among elderly patients in primary care

Depression may play an important role in determining frequent physician visits in the older population. Our aim is to examine the relationships between socio-demographic variables, co-morbidity, memory complaints, functional status, depressive symptomatology, and health care utilization among community dwelling older patients. The study was conducted in urban primary health care clinics in Beer-Sheva, Israel. Two groups were identified: low care utilizers (LCU), with ≤6 visits to family physicians (FP)/year and high care utilizers (HCU) with ≥16 visits to FP/year. Data were collected during a structured face-to-face individual interview. The study population included 180 patients, of them 86 (47.7%) were LCU and 94 (52.2%) were HCU. In all clinical measurements the HCU group indicators were statistically significant worse off than the LCU group: average depressive symptoms (5.6 vs. 2.5, p < 0.01), memory complaints (57.5% vs. 23.3%, p < 0.01), Barthel Index (BI) (89.9 vs. 96.0, p < 0.001), OARS (10.8 vs. 12.5, p < 0.01), and co-morbidity: total cumulative score (TCS) of Charlson comorbidity index (CCI) (2.2 vs. 1.3, p < 0.01). Our study raises the possibility that at least one of the reasons for over-utilization of health services by older residents in the community is depressive symptomatology.     

Utilization of health resources in South Asian,Chinese and White patients with diabetes mellitus

AimsWe sought to determine whether there are differences in health resource utilization among South Asian (SA), Chinese and White patients with newly diagnosed diabetes mellitus.MethodsWe used province-wide administrative data from British Columbia, Canada (1997–2006) to determine proportion of patients with ≥2 visits/year for all outpatient and family physician (FP) visits, proportion of patients with at least one annual visit to specialists, ophthalmology/optometry and hospital admissions by ethnic group.ResultsThere were 9529 South Asian, 14,084 Chinese and 143,630 White patients with newly diagnosed diabetes in the study. Over 90% of each of the ethnic groups visited their FP ≥2 visits/year. Chinese patients were less likely to visit FP, ophthalmology/optometrists and specialists compared to White patients. SA patients had fewer ophthalmology/optometry visits compared to White populations. White patients had higher rates of hospitalization.ConclusionAlthough all groups had high proportion of patients with appropriate frequency of FP visits, other aspects of health care utilization varied significantly by ethnicity.     

Identification of case complexity and increased health care utilization in patients with rheumatoid arthritis

Objectives To document biopsychosocial profiles of patients with rheumatoid arthritis (RA) by means of the INTERMED and to correlate the results with conventional methods of disease assessment and health care utilization.

Methods

Patients with RA (n = 75) were evaluated with the INTERMED, an instrument for assessing case complexity and care needs. Based on their INTERMED scores, patients were compared with regard to severity of illness, functional status, and health care utilization.

Results

In cluster analysis, a 2‐cluster solution emerged, with about half of the patients characterized as complex. Complex patients scoring especially high in the psychosocial domain of the INTERMED were disabled significantly more often and took more psychotropic drugs. Although the 2 patient groups did not differ in severity of illness and functional status, complex patients rated their illness as more severe on subjective measures and on most items of the Medical Outcomes Study Short Form 36. Complex patients showed increased health care utilization despite a similar biologic profile.

Conclusions

The INTERMED identified complex patients with increased health care utilization, provided meaningful and comprehensive patient information, and proved to be easy to implement and advantageous compared with conventional methods of disease assessment. Intervention studies will have to demonstrate whether management strategies based on INTERMED profiles can improve treatment response and outcome of complex patients.

     

Impact of health maintenance organizations and fee‐for‐service on health care utilization among people with systemic lupus erythematosus

Objective

To compare health care utilization in people with systemic lupus erythematosus (SLE) in health maintenance organizations (HMOs) and fee‐for‐service (FFS).

Methods

A structured survey was administered to a cohort of 982 people with SLE who were assembled between 2002 and early 2005. A total of 2,656 person‐years of observation were completed by the end of 2005. In each year, respondents reported their health care utilization and whether they had HMO or FFS coverage. We compared health care utilization of those in HMOs and FFS, with and without adjustment for socioeconomic, demographic, and health characteristics using repeated‐measures regression techniques.

Results

Compared with people with SLE who were in FFS, those in HMOs were younger (3.3 years), received a diagnosis at an earlier age (3.6 years), had slightly less disease activity (0.4 on a 10‐point scale), were more likely to be nonwhite (8.8%), were less likely to be below the poverty line (7.8%), and were less likely to have public insurance (29.7%). The 2 groups did not differ in other characteristics. On an unadjusted basis, subjects with SLE in HMOs had significantly fewer physician visits (3.1; 95% confidence interval [95% CI] 1.7, 4.5) and were less likely to report one or more outpatient surgical visits (6.3%; 95% CI 2.5, 10.0), and hospital admissions (5.5%; 95% CI 1.7, 9.3) than those in FFS. Adjustment reduced the differences in physician visits (2.3; 95% CI 1.1, 3.5), outpatient surgical rates (4.4%; 95% CI 0.6, 8.1), and hospital admission rates (4.0%, 95% CI 0.4, 7.7).

Conclusion

Subjects with SLE in HMOs utilized substantially less ambulatory care and were less likely to have outpatient surgery and hospital admissions than those in FFS; the effects were not completely explained by socioeconomic, demographic, and health characteristics.

     

Ambulatory health care utilization of the older people under the National Health Insurance in Taiwan

Background/Purpose

To analyze and describe the patterns of ambulatory care utilization by the older people within the Taiwanese National Health Insurance (NHI) program.

Methods

The nationwide computerized claims database of elderly ambulatory care visits under the NHI in 2004 was accessed. We obtained the complete outpatients service claim data sets of Western medicine for beneficiaries ≧ 65 years old. We then analyzed the pattern and frequency of visits by patient age, sex, and primary diagnosis.

Results

In 2004, 96.6% of all elderly NHI beneficiaries had ever used ambulatory care service and there were totally 57,101,420 ambulatory care visits records from these elderly beneficiaries. The average ambulatory visit number of each beneficiary is 26.8 ± 22.7 (mean ± standard deviation) times per year, which was much higher than United States and other Organization for Economic Co-operation and Development countries. Nearly one-half of the elderly had more than 24 times visits annually. Female beneficiaries had higher average annual ambulatory visit number but lower mean medical expense per visit than male beneficiaries. The middle old age group (75–84 years old) had highest average visits numbers (29.2 ± 23.3) and highest average medical expense per visit: 37.1 US dollar. The three most frequent principal diagnoses of elderly ambulatory visits were diseases of the circulatory system (17.3%), diseases of the respiratory system (15.9%), and diseases of the musculoskeletal system and connective tissue (12.8%), respectively. While compared with United States data, the proportion of acute upper airway infection was much higher among old age ambulatory visits in Taiwan.

Conclusion

The mean frequency of ambulatory visits of older people in Taiwan was high, especially in the middle-old age group. Health education and preventive services should focus on circulatory, respiratory, and musculoskeletal diseases, which accounted for nearly one-half of the primary diagnoses of old age ambulatory visits.     

Sexual and physical abuse in women with fibromyalgia: Association with outpatient health care utilization and pain medication usage

Objective. To evaluate the relationship between sexual and/or physical abuse and health care usage in patients with fibromyalgia (FM) and identify variables that may influence this relationship. Methods. We assessed history of sexuall physical abuse, health care utilization, and medication usage, as well as related variables in 75 women with FM using standardized questionnaires, structured interviews, and laboratory pain perception tasks. Results. Fifty-seven percent of FM patients reported a history of sexuall physical abuse. Compared to non-abused patients, abused patients reported significantly greater utilization of outpatient health care services for problems other than FM and greater use of medications for pain (P ≤ 0.025). Consistent with our expectations, abused patients also were characterized by significantly greater pain, fatigue, functional disability, and stress, as well as by a tendency to label dolorimeter stimuli as painful regardless of their intensities (P ≤ 0.05). Additional analyses suggested that the high frequency of sexuall physical abuse in our patients was associated primarily with seeking health care for chronic pain rather than the FM syndrome itself or genetic factors. Conclusion. There is an association in FM patients between sexuall physical abuse and increased use of outpatient health care services and medications for pain. This association may be influenced by clinical symptoms, functional disability, psychiatric disorders, stress, and abnormal pain perception. The relationships among these variables should be further tested in prospective, population-based studies.     

Impact of the severity of hypoglycemia on health - Related quality of life,productivity, resource use,and costs among US patients with type 2 diabetes

Aims

To explore the association between hypoglycemia severity and health-related quality of life (HRQoL), productivity, health care resource utilization (HCRU), and costs among patients with type 2 diabetes mellitus (T2DM).

Impact of diabetes education teams in primary care on processes of care indicators

AimsTo evaluate the impact of the integration of onsite diabetes education teams in primary care on processes of care indicators according to practice guidelines.MethodsTeams of nurse and dietitian educators delivered individualized self-management education counseling in 11 Ontario primary care sites. Of the 771 adult patients with HbA1c ≥7% who were recruited in a prospective cohort study, 487 patients attended appointments with the education teams, while the remaining 284 patients did not (usual care group). Baseline demographic, clinical information, and patient care processes (diabetes medical visit, HbA1c test, lipid profile, estimated glomerular filtration rate, and albumin-to-creatinine ratio, measuring blood pressure, performing foot exams, provision of flu vaccine, and referral for dilated retinal exam) were collected from patient charts one year before (pre period) and after (post period) the integration began. A multi-level random effects model was used to analyze the effect of group and period on whether the process indicators were met based on practice guidelines.ResultsCompared to the usual care group, patients seen by the education teams had significant improvements on indicators for semi-annual medical visit and annual foot exam. No significant improvements were found for other process of care indicators.ConclusionsOnsite education teams in primary care settings can potentially improve diabetes management as shown in two process of care indicators: medical visits and foot exams. The results support the benefits of having education teams in primary care settings to increase adherence to practice guidelines.     

Do physicians with diabetes have differences in dialysis use and survival than other patients with diabetes

Aims

To assess whether the increased knowledge and resources available to physicians led to differences in dialysis and survival rates between physicians and non-physician patients with diabetes.

Methods

All newly diagnosed (1997–2009) type 2 diabetes patients aged ≥35 years from the National Health Insurance Program of Taiwan database were included. After propensity score matching (1:10), we estimated the relative risk of dialysis and death using Cox proportional hazards model adjusted for demographic characteristics and comorbidities.

Results

Physicians with diabetes were more likely to start dialysis than general patients, with a 48% increased hazard risk (HR) (P = 0.006). Physicians with diabetes had significantly lower risk of death (HR: 0.88; P = 0.025). However, those requiring dialysis had a non-significant increased risk of death (HR: 1.19). There was an increased HR for death in older physicians (HR: 1.81; P < 0.001) and those with cancer or catastrophic illness. The HR of dialysis (7.89; P < 0.0001) increased dramatically with increasing Charlson Comorbidity Index scores.

Conclusions

Physicians with DM survived longer than other patients with diabetes, likely benefiting from their professional resources in disease control and prevention. Nonetheless, they displayed no advantage from their medical backgrounds compared with the general patients if they developed end stage renal disease.     

Determinants of survival and attempted resection in patients with non-metastatic pancreatic cancer: An Australian population-based study

BackgroundThere are indications that pancreatic cancer survival may differ according to sociodemographic factors, such as residential location. This may be due to differential access to curative resection. Understanding factors associated with the decision to offer a resection might enable strategies to increase the proportion of patients undergoing potentially curative surgery.MethodsData were extracted from medical records and cancer registries for patients diagnosed with pancreatic cancer between July 2009 and June 2011, living in one of two Australian states. Among patients clinically staged with non-metastatic disease we examined factors associated with survival using Cox proportional hazards models. To investigate survival differences we examined determinants of: 1) attempted surgical resection overall; 2) whether patients with locally advanced disease were classified as having resectable disease; and 3) attempted resection among those considered resectable.ResultsData were collected for 786 eligible patients. Disease was considered locally advanced for 561 (71%) patients, 510 (65%) were classified as having potentially resectable disease and 365 (72%) of these had an attempted resection. Along with age, comorbidities and tumour stage, increasing remoteness of residence was associated with poorer survival. Remoteness of residence and review by a hepatobiliary surgeon were factors influencing the decision to offer surgery.ConclusionsThis study indicated disparity in survival dependent on patients' residential location and access to a specialist hepatobiliary surgeon. Accurate clinical staging is a critical element in assessing surgical resectability and it is therefore crucial that all patients have access to specialised clinical services.     

Rural-urban gaps in health care utilization among older Thais: The role of family support

This study examined rural-urban differences in health visits among older Thais utilizing Andersen’s model. Data were drawn from the 2011 Survey of Older Persons in Thailand of adults 50 years and older (N = 56,435). Logistic regression models examine individuals’ predisposing, enabling, and health need factors for explaining older adults’ health care use. Approximately 50% of older adults sought health care but urban dwellers were more likely than rural dwellers to seek health care (54.8% vs. 49.7%). Predisposing factors and health needs narrow the rural-urban gap while enabling factors widened the gap in health visits. The receipt of financial support from children presented a significant moderating effect in the rural-urban divide of health care use. Despite Thailand’s universal access to health care, geographic inequity in health care utilization withstands. Findings suggest investments in education, income security, social participation, and healthy lifestyle promotion can improve health care utilization. Furthermore, results suggest a need for continued investigation of the role of family support in bridging the rural-urban divide in the health of older Thais.     

抗病毒治疗对乙型肝炎相关肝癌根治术后复发和生存的影响

目的探讨口服核苷(酸)类似物抗乙型肝炎病毒(HBV)治疗对原发性肝癌根治术后患者复发和生存的影响。方法收集2004年1月至2006年12月期间在我科行根治术的血清HBV DNA阳性的具有完整的临床和随访资料的肝癌患者156例。术后分为单纯手术的对照组80例和同时接受手术和核苷类似物抗病毒治疗的76例,抗病毒方案为口服拉米夫定/阿德福韦酯或恩替卡韦。应用Kaplan-Meier法比较两组术后无复发生存率和总生存率的差异。结果 76例接受抗病毒治疗患者术后1 m和3 m血清HBV DNA水平分别为(1.63±1.15)×104copies/ml和1×102copies/ml,较抗病毒前显著降低(P0.05),而80例未抗病毒治疗患者血清HBV DNA水平无明显变化;未抗病毒组患者平均无复发生存时间为(10.25±2.56)月,而抗病毒组为[(21.43±3.35)月,P0.01];未抗病毒组和抗病毒组患者1 a、3 a、5 a无复发生存率分别为54.6%、22.3%、0.0%和73.1%、36.2%、23.4%,两组差异有统计学意义(P0.05);未抗病毒组患者平均总生存时间为(18.42±3.21)月,抗病毒治疗组为[(30.28±2.62)月,P0.01];未抗病毒治疗组和抗病毒组患者1 a、3 a、5 a总生存率分别为81.2%、42.0%、16.3%和92.2%、73.4%、31.6%,两组差异有统计学意义(P0.05)。结论对于血清HBV DNA阳性的肝癌患者,在根治术后给予规范的抗病毒治疗可以改善预后,延长生存时间。     

Glycaemic control and diabetes care utilization in young adults with Type 1 diabetes1

Objectives To explore how glycaemic control in young adults is related to diabetes care utilization during the transition to adult diabetes care and if these variables differ between males and females. Methods This is a retrospective, longitudinal design following patients’ records from age 18–24 years. Adolescents (n = 104) connected to one paediatric outpatient clinic and referred to six different adult clinics were included. Data were collected regarding gender, age at diagnosis and transfer, yearly glycated haemoglobin (HbA_1c) and body mass index, severe hypoglycaemia and diabetic ketoacidosis, retinopathy and diabetes care utilization. Results HbA_1c decreased over time in females (P = 0.004) but not in males. Less than 10% had HbA_1c in the recommended range during the study period. The decrease in severe hypoglycaemia and diabetic ketoacidosis was not significant. The prevalence of background retinopathy increased from 5 to 29% during the study period (P < 0.001). Mean transfer age was 19.8 years. The youths visited the paediatric clinic more often than the adult clinic (P < 0.001) and females visited adult care more often than males (P = 0.04). There was a steady decrease in the number of visits/year over time (P < 0. 001). Poor glycaemic control was associated with more visits for both males and females (P = 0.005) in adult care. Conclusions As there was no gender difference in the relation between HbA_1c and the number of visits in adult diabetes care, the higher frequency of visits in adult care for females cannot be solely explained by their glycaemic control. Gender differences regarding diabetes care utilization should be further explored.     

Referral rates of patients with diabetes to secondary care are inversely related to the prevalence of diabetes in each primary care practice and confidence in treatment,not to HbA1c level

AimsTo determine the factors affecting the referral rates of patients with diabetes from primary care to secondary care.MethodsA study based on 66 GP surgeries in the Cardiff and Vale University Health Board (population: 515,581) was conducted. We included patients who had an established clinical diagnosis of diabetes (type 1 and type 2) from September 2017 to September 2018.HbA1c outcome data of GP surgeries were obtained from the Quality and Outcomes Framework (QOF) database published for 2018. Referral rates were obtained from the electronic referral database of Cardiff and Vale University Health Board over the same period, and this was adjusted according to the number of patients with diabetes in each GP surgery. Confidence level on the treatment of diabetes among GPs was assessed as a sub-study conducted in nine GP surgeries in the same area, using a self-administered questionnaire. Linear regression was undertaken to assess the relationship between adjusted referral rate and key factors which might influence prescribing rate.ResultsThe average adjusted referral rate to secondary care in one year was 4.23% of patients with diabetes in each GP surgery, with a wide variation of 1.24% to 16.28%. The average percentage of patients with diabetes with HbA1c < 59 mmol/mol was 63.17% (range: 43.19–76.23%). The average confidence score of GPs in treating diabetes was 67% and ranged from 50–85% in the sub-study. Referral rates correlated inversely with the numbers of patients with diabetes in each practice β = ?0.32; (95% CI ?0.57, ?0.08) p = 0.01, but there was no significant correlation with the HbA1c outcome β = ?0.13; (95% CI ?0.39, 0.12); p = 0.30. Borderline significant negative correlation was observed between referral rates and overall practice size β = ?0.23; (95% CI ?0.48, 0.02) p = 0.07.ConclusionsReferral rates of patients with diabetes to secondary care are determined by the number of patients with diabetes in each practice and confidence level in treatment, not by the overall practice size or HbA1c level. Ensuring quality training in diabetes care for primary care teams as well as the development of integrated diabetes care may be the best way to optimise the volume and appropriateness of referrals to secondary care.     

Knowledge levels and attitudes of health care professionals toward patients with hepatitis C infection

AIM: To study knowledge levels and attitudes of health care providers toward patients with hepatitis C virus infection in Guilan, a northern province of Iran.METHODS: This cross-sectional study was performed on 239 health care professionals from the Razi Hospital, including doctors, nurses, and operating room technicians. The questionnaires consisted of questions on demographic characteristics, knowledge levels, and attitudes toward hepatitis C patients. The questionnaire was tested in a pilot study and validated by Cronbach’s alpha coefficient. Data were analyzed using SPSS16 software.RESULTS: The mean ± SD knowledge score was 17.43 ± 2.65 (from a total of 22). 51.9% of the participants achieved scores higher than the mean. There was a significant relationship between knowledge score and age (P = 0.001), gender (P = 0.0001), occupational history (P = 0.0001), and educational history (P = 0.027). There was also a significant relationship between attitude level and age (P = 0.002), gender (P = 0.0001), occupational history (P = 0.0001), and educational history (P = 0.035). Physicians were significantly more knowledgeable and showed more positive attitudes. There was a positive correlation between knowledge and attitude scores (P = 0.02).CONCLUSION: Discriminatory attitudes are common among health care providers toward hepatitis C patients. It is therefore necessary to improve their knowledge level and attitude toward this disease.